PROOF OF INSURANCE (2016) CLOSEDAC R CERTIFICATE OF LIABILITY INSURANCE DATI'e(MM/DDrVYYY)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(iss) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CO7'TE. Hammer, CIC ._.
1118 _
Crescents Valley Insurance PHONE �r`A
NAP�INEm_„
eA ltr� SIX• karenC�c- _ .. ., .... 1 rtrD f5 l
3156 Foothill Blvd. Ste A E-MAIL ins.COm
La Crescents, CA 91214.. . m_ .._ ......................_.....
License #: OC91996 INSURER 31 AFFORDING COVERAGE NAIL!
INSURERA: Harry W_ Gorat Co_ Inc_
............ ....._...._.................... ......... ...._ _ ......_._
'.. INSURED INSURER B: Mercurv..Insurance Grouo COMMERCIAL 38342
Sandmaster, Inc.
DBA Sand master Sandblaster INSURERC: State Compensation Insurance Fund
3348 Burritt Way INSURER D: ITITITmm ....
La Crescents, CA 91214 INSURERS ; _ ......
INSURER F
I
COVERAGES CERTIFICATE NUMBER: 00000000. 110651 REVISION NUMBER: 5
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NI�9�q A DL SU .._._ Sf1 POUCY ECF POLNCY EXP �-- --.._....... ._.....
T. TYPE OF INSURANCE "SO POLJCV NUMBER. M {kp Y Y LIMITS
A COMMERCIAL GENERAL LIABILITY Y ACH 737994PC 1 WO12015 10/30/2016 EACH OCCURRENCE $ 1.000.000
CLAIMS-MADE NxI OCCUR P b'I� :( $ 50.000
. .............................
.._.......... ..,.,................. ...............
... MED IXP fArry 5.000
PERSONAL &ADV INJURY $ 1.000.000
........ .. _... ....... _r---
- -
GEN'LAGG"„REGATELIMITAPPLIES PER: GENERAL AGGREGATE S 2.000.000
PO-
R ..00Y F -1 JET EI LOC PRODUCTS - COMP /OPAGG $ 2.000.000
......... _.._ .....................
OIB`69ER: � ... $
B AUTOMOBILE LIABILITY BA040000024762 12/01/2015 12/01/2016 E22�ideDSwGLELI I $ 1.000.000
ANYAUTO BODILY INJURY (Per person) I $
ALL OWNED SCHEDULED BODILY INJURY (Per accident)� $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS ....... AUTOS ..IP1.�.1"r�{�19.J;U�d ..... ....
UMBRELLALIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB......_..._.
HCLAIMS-MADE AGGREGATE '.. $
DED "I RETENTION S $
WORKERS COMPENSATION II PER OTH
C AND EMPLOYERS' LIABILITY 163546015 05/17/2015 05J17/2016 X _PER ITF FR
ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N EL. EACHACCIDENT I$ - -mmmm 11000,000
OFFICER/MEMBEREXCLUDED? �N /A ........ ....... ...------- . --.•.- ....
(Mendetory In NH) E L DISEASE EA EMPLOYE $ 1,000,000
8f e� describe under
L6 5 """"Soo'. E L DISEASE - POLICY LIMIT $ 1.000.000
DESCRIPTION OF OPERATIONS! LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Ia required)
The City of El Segundo, its officials, and employees are included as additional insured with respect to liability arising out of
the named insured operations per additional insured endorsement attached. This coverage is primary. 30 day notice of
cancellation applies, except for non- payment then 10 days.
CERTIFICATE HOLDER CANCELLATION
THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Person Or Organization:
Any person or organization with whom the Insured has agreed within a written contract or written agreement;
provided such written agreement Is executed prior to the loss. 4
A. Section If -Who Is An Insured is amended to
include as an insured the person or organization
shown in the Schedule, but only with respect to
liability arising out of your ongoing operations
performed for that insured.
B. This insurance is Primary and Non - Contributory,
but only for the Additional Insured shown in the
schedule and only for liability arising from the
Insured's negligence for ongoing operations.
C. With respect to the insurance afforded to these
additional insureds, the following exclusion is added
2. Exclusions
(1) All work, including materials, parts or
equipment furnished in connection with
such work, on the project (other than
service, maintenance or repairs) to be
performed by or on behalf of the additional
insured(s) at the site of the covered
operations has been completed; or
(2) That portion of " your work" out of which
the injury or damage arises has been put
to its intended use by any person or
organization other than another contractor
or subcontractor engaged in performing
operations for a principal as a part of the
This insurance does not apply to " bodily injury" same project.
or "property damage" occurring after:
AGL -153 08 14 Includes copyrighted material of the Insurance Services Page 1 of 1
Office, Inc., used with permission. All rights reserved.
POLICY NUMBER: M227000085
COMMERCIAL GENERAL LIABILITY
CG 24 04A 05 09
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following.
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization: Any person or organization with whom the Insured has agreed within
a written contract to waive rights of recovery, provided such written agreement is executed prior to the
loss.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations
The following is added to Paragraph 8.
Transfer Of Rights Of Recovery Against
Others To US of Section IV - Conditions:
We waive any right of recovery we may
have against the person or organization
shown in the Schedule above because of
payments we make for injury or damage
arising out of your ongoing operations or "
your work" done under a contract with that
person or organization and included in the
"prod operations hazard ".
This waiver applies only to the person or
organization shown in the Schedule above.
CG 24 04A 05 09 Copyright, Insurance Services Office, Inc., 2008 Page 1 of 1 ❑
ENDORSEMENT AGREEMENT
WAIVER OF SUBROGATION
1635460 -15
RENEWAL
SC
1- 60 -42 -00
PAGE 1
HOME OFFICE
SAN FRANCISCO EFFECTIVE MARCH 31, 2016 AT 12.01 A.M.
AND EXPIRING MAY 17, 2016 AT 12.01 A.M.
ALL EFFECTIVE DATES ARE
AT 12:01 AM PACIFIC
STANDARD TIME OR THE
TIME INDICATED AT
PACIFIC STANDARD TIME
SANDMASTER SANDBLASTING
3348 BURRITT WAY
LA CRESCENTA, CA 91214
ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING,
IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND
WAIVES ANY RIGHT OF SUBROGATION AGAINST,
CITY OF EL SEGUNDO
WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS
POLICY IN CONNECTION WITH WORK PERFORMED BY.
SANDMASTER SANDBLASTING
IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN
PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION
OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE
EMPLOYER.
IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH
EMPLOYEES SHALL BE INCREASED BY 03%.
NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE
OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS
POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE
HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR
LIMITATIONS OF THIS ENDORSEMENT,
COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: APRIL 4, 2016
f
AUTHORIZED REPIE'aE'NT IVE PRESIDENT AND CEO
SCIF FORM 10217 IREV.7 -2014)
2570
OLD DP 217